Hill House

Hill House is a 'care home'. Hill House accommodates 30 people in one adapted building. They provide care and support for older people and some people were living with dementia. At the time of our inspection there were 29 people living at the service.

People’s experience of using this service and what we found

The provider had made improvements at the service to embed quality assurance processes to monitor the quality and safety of the care people received. They had produced an action plan which they were working through. At the time of this inspection previous breaches had been met but the quality assurance processes required further embedding to ensure all records were up to date and accurate.

Since the last inspection, a new manager has been appointed and has been registered with the Care Quality Commission. People using the service, relatives, staff and professionals commented on the improvements at the service since the arrival of the registered manager. One relative said, “There’s better quality staff, who are kind and caring. Admin and communication have improved greatly. The atmosphere is so much better”. A professional said, “I have positive encounters with the registered manager and deputy manager when I visit, who appear to really care about their residents”.

People received safe care at the service. All those spoken with said they felt safe at the service. Relatives and professionals also expressed their confidence in the service. Comments included, “I am settled and happy here. I can't grumble and I wouldn't be anywhere else”. A professional said staff seemed “well informed and able to recognise when referrals to other services are appropriate.” A relative told us, “(Person’s) health and wellbeing has improved; she is amazing now and getting on so well”.

Since the last inspection, staffing levels had increased to ensure people received care in a timely way. Staff training had been addressed to ensure they had the skills to meet people’s needs and staff received supervision and appraisals to ensure their practice was as expected.

Improvements had been made to ensure pressure relieving equipment was used safely. All pressure mattresses were set at the correct setting. Staff knew when people were at risk and followed instructions to keep people safe.

Medicines were safely managed. Improvements in medicines management had been made since we last visited. However, attention was needed to ensure records relating to topical creams were accurate.

People were protected from abuse as staff knew who to report concerns about people's safety to.

We were assured that the provider was preventing visitors from catching and spreading infections. The registered manager was facilitating visits for people living in the home in accordance with the current guidance.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

The registered manager sought the views of the people living at the service and their relatives. Residents’ meetings had been re-established and provided a forum for discussion about any changes to the service and to hear of any suggestions for improvements.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement and there were breaches of regulation (published 15 April 2021). The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

At our last inspection we recommended that the provider review staffing levels and the deployment of staff to ensure people's needs were met in a timely way. At this inspection we found the provider had increased staffing levels.

Why we inspected

We undertook this unannounced focused inspection to check the provider had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions, Safe and Well-led which contain those requirements.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Hill House on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Hill House is a 'care home'. Hill House accommodates 30 people in one adapted building. At the time of our inspection there were 26 people living at the service.

People’s experience of using this service and what we found

Devon County Council implemented a safeguarding process in February 2021, which was on-going at the time of the inspection. The provider was working with the local authority in an open and candid way during the investigation.

Effective arrangements were not in place to mitigate all risks for people using the service. People were placed at risk of harm because the management of medicines was not always effective. Medicines audits had not identified the concerns we found during the inspection.

Risks to people’s health and wellbeing were not always identified or mitigated to ensure safe care was consistently delivered. For example, in relation to the use of pressure relieving equipment; falls management and the risk presented to people who required support with diet and fluids.

Quality assurance and governance arrangements at the service were not always reliable or effective and had not identified some shortfalls at the service.

We have signposted the provider to resources to develop their approach to good infection prevention and control practice.

We have recommended the provider review staffing levels and the deployment of staff to ensure people’s needs were met in a timely way.

People and relatives were positive about the caring nature of staff and the service they received. Comments included, "It has been lovely here; it's beautiful. Staff are helpful and friendly"; “I have no complaints about any of my dealings with any of the staff” and “I cannot praise the staff highly enough as they have gone the extra mile…”

Systems were in place which ensured safety checks and maintenance was completed for equipment such as hoists, gas and electrical installations.

The provider had policies and procedures in place designed to protect people from the risk of harm and abuse. Staff and the management team were aware of how and when to report any concerns about people’s wellbeing.

Accidents and incidents were recorded and analysed to help the provider ensure when things went wrong, issues were investigated, and lessons were learnt.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 05 September 2018).

Why we inspected

The inspection was prompted in part due to safeguarding concerns in relation to the safety of people using the service. As a result, we undertook a focused inspection to review the key questions of safe and well-led. Our report is based on the findings in those areas at this inspection. The ratings from the previous comprehensive inspection for the Caring, Effective and Responsive key questions were not looked at on this occasion.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Enforcement

We have found evidence the provider needs to make improvements. At this inspection we found a breach of Regulation 12, safe care and treatment, and regulation 17. Good governance. This service has been rated requires improvement in safe and well-led. The rating is requires improvement overall.

You can see what action we have asked the provider to take at the end of this full report.

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Hill House on our website at www.cqc.org.uk.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Hill House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Hill House accommodates 30 people in one adapted building. At the time of our inspection there were 30 people living at the service.

Following the last inspection in August 2017, we asked the provider to complete an action plan to show what they would do and by when to improve the key question(s) Safe, Effective, Responsive and Well-led to at least good. At the previous inspection, we found the provider had failed to ensure staff received appropriate support, training and supervision. The provider also did not operate effective systems to ensure improvements were made to the quality and safety of the service. Records were not always accurate, complete and contemporaneous in respect of each service user. This inspection found improvements had been made. Staff were now receiving up to date training and support and systems to monitor the quality and safety of the service were more robust.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Staffing levels met people’s personal care needs. However, meaningful interactions were limited. The service was actively trying to recruit more staff to increase staffing levels. The service provided safe care to people. One person commented: “It's the staff, they make me feel safe”. Measures to manage risk were as least restrictive as possible to protect people’s freedom. People’s rights were protected because the service followed the appropriate legal processes. Medicines were safely managed on people’s behalf.

Care files were personalised to reflect people’s personal preferences. Their views and suggestions were taken into account to improve the service. People were supported to maintain a balanced diet. Health and social care professionals were regularly involved in people’s care to ensure they received the care and treatment which was right for them.

Staff relationships with people were caring and supportive. Staff were motivated to offer care that was kind and compassionate.

There were effective staff recruitment and selection processes in place. People received effective care and support from staff who were well trained and competent.

Staff spoke positively about communication and how the registered manager worked well with them.

A number of more robust methods were used to assess the quality and safety of the service people received. The service made continuous improvements in response to their findings.

Further information is in the detailed findings below.

This inspection took place on 27 and 28 April 2017. The first day of the inspection was unannounced. The service was last inspected on 28 May and 3 June 2015 when it was rated as good overall with responsive rated as requires improvement due to inconsistencies in record keeping. We issued a requirement. The provider had developed an action plan to ensure improvements were made. We found improvements had been made to some records but not consistently.

Prior to the inspection we received concerns from a visiting professional about staffing levels and concerns that people’s personal care was delayed and that they were isolated in their rooms due to staffing levels. There were concerns that some people did not appear to have access to their call bells when in their room. There were concerns about people who may be at risk of falls and some undocumented bruising found on two people. Medicines were not always stored securely in people’s rooms. We looked at all aspects of these concerns during the inspection. We also received an anonymous concern about the attitude of one staff member. This was thoroughly investigated by the provider and was not substantiated.

There was a manager at the service who was registered with CQC. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Staffing levels at the service were meeting people’s care needs; however due to high levels of sickness and the use of agency staff people expressed frustration that often staff did not know them well or understand their needs. Some people felt this and the approach of some staff impacted on their feeling of safety.

Some aspects of medicines management needed to improve to ensure practice was safe.

Staff had the knowledge they needed and understood people’s needs in order to carry out their roles; however several aspects of staff training had lapsed and some training was out of date, with staff requiring refresher training. Staff received annual appraisals however supervision of staff had lapsed.

Systems in place to monitor and improve the quality and safety of the service were not fully effective and timely action was not taken in response to known issues.

The majority of people said they felt safe. They were protected against the risk of abuse as the registered manager and staff understood their responsibilities to report any concerns. Plans were in place to keep people safe in emergency situations.

Risks to people using the service were assessed and plans put in place to reduce the chances of them occurring. Regular checks were made of the premises and equipment to ensure they were safe for people to use. Procedures were in place to monitor and respond to accidents and incidents. Staff were recruited using robust procedures intended to protect people from unsuitable workers.

People’s rights were protected because the registered manager acted in accordance with the Mental Capacity Act 2005.

People’s nutritional needs were met. Mealtimes were sociable and the registered manager was working to ensure people’s preferences with regards to food were also being met. People had access to a variety of health professionals for specialist advice and support when appropriate. The service had developed good working relationships with health and social professionals.

Overall people felt staff were kind and caring. Two people felt the approach of some staff was not as caring as others. Where people had raised concerns with the registered manager, these had been addressed and improvements were noted. We also saw good interactions from staff, where they worked in ways that were kind and respectful of people.

Care plans were generally detailed containing information about people’s health and personal care needs, and preference, with the exception of one. Permanent staff knew people well. We received mixed feedback about the activities provided. The registered manager was aware that activities would benefit from development.

People had the opportunity to engage with the service and provide their feedback and suggestions about improvements. However, timely action to address feedback and suggestions had not always been taken.

We identified two breaches of regulations at this inspection. You can see what action we told the provider to take at the back of the full version of the report.

We considered our inspection findings to answer questions we always ask;

Is the service safe?

Is the service effective?

Is the service caring?

Is the service well led?

This is a summary of what we found. If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

The service was not following the Mental Capacity Act 2005 for people who lacked capacity to make a decision. The provider had not made an application under the Mental Capacity Act Deprivation of Liberty Safeguards for one person, even though their liberty may have been restricted.

People were not always protected against the risks of unsafe or inappropriate care because the planning and delivery of care did not always meet people's individual needs. Where needs had changed, the care plan and risk assessment did not fully reflect the changes or provide guidance to staff to ensure a consistent approach to the delivery of care and support.

All the people we spoke with who lived at the home said that they felt safe and did not have any concerns about abuse or bullying. One person told us, 'My falls are non-existent since moving here. I do feel safer here'. Another commented, 'No-one tells me what to do or pushes me around'. People told us their care was never rushed.

The three relatives we spoke to also said that they were not concerned about their loved ones' safety at the home. One commented, 'It is a relief to know X is well looked after'. One health professional told us, 'We have never seen any practice which concerns us'.

People who used the service, staff and visitors were protected against the risks of unsafe or unsuitable premises. We found all areas, communal areas and private bedrooms, were in good decorative order, well maintained, fully accessible, and clean and free from odours.

We found there were effective recruitment and selection processes in place when we checked staff files.

Although the home had experienced some staff shortages due to sickness there was no evidence that people's immediate care and support needs had not been met as a result. This was due to the effective team work and dedication of the staff.

Is the service effective?

Staff were provided with training to ensure they had the skills to meet people's needs.

New staff received induction training when they started work to ensure they worked safely with people and fully understood their roles and responsibilities.

People living at the home and their relatives told us they were happy with the care and support staff provided and people's needs were met.

Staff had a good understanding of most people's care and support needs and they knew how to meet them and avoid unnecessary risks.

External health and social care professionals told us the service worked well with them. They said there was effective communication which promoted the health and wellbeing of people at the home.

Is the service caring?

We saw staff offering care and support to people throughout the inspection. Staff treated people with respect and their approach was friendly and supportive.

We spoke with 14 people. All confirmed that they were happy with the care and support provided. They said, 'I have made friends here. It is very nice. It is home now'; 'Staff have the patience of a saint. The majority of staff are very kind and considerate' and 'It is very nice here, I'm happy".

We spoke with three relatives. They said they were happy with the care and support their loved ones received. Comments included, "X's mobility has improved greatly since moving here thanks to the patience and encouragement of staff', and 'The staff are very kind and caring. The home is wonderful' Visiting professionals told us, 'Staff are always mindful of people's privacy and dignity. We see them knocking on doors. They speak with people respectfully' and 'Staff are very attentive'.

Is the service responsive?

People's preferences and interests had been recorded and care and support had been provided in accordance with people's wishes. People were able to join in with a range of activities which they enjoyed and found interesting.

We observed staff responding to people's requests for assistance in a timely way. We saw staff helping people with their daily activities such as personal care and social activities. Care and support was delivered as requested. This showed that staff were responsive, professional and respectful towards people living at the home.

Records showed health professionals such as GPs, community nurses, speech and language therapists and dieticians were contacted when the service had concerns about people's health.

Is the service well-led?

People using the service, their relatives and visiting health and social care professionals told us they felt the service was well run and managed. All those spoken with had confidence in the manager of the home. Comments included, 'You can speak with the manager about any concerns and she listens'; I have confidence in the manager. I feel the overall standard of care is very good'; and 'This is a well-run place. It is very popular with our patients and I would recommend it to people'.

The manager and provider monitored the quality of the service provided by completing regular audits of medicines management, care records and infection control. They evaluated these audits and created action plans for improvement, when improvements were needed.

People living at Hill House were involved in the assessment and monitoring of the quality of service. The results from the last quality survey showed high satisfaction scores were achieved for all aspects of the service.

Records showed that staff recorded incidents that happened. The manager used this information to monitor and investigate the majority of incidents. Appropriate action was taken where necessary to reduce the risk of them happening again.

One person said, 'there is an air of general cheerfulness about the home'. Another person said, 'staff are very good, they come quickly if I need help'. A third person said the best thing about the home is 'being looked after'.

Since we last visited, communal areas of the home had been refurbished and redecorated and some bathroom areas upgraded. People were very pleased with the improvements made. The registered manager told us how mood boards were used to consult with people about the colour schemes and fabrics proposed for each room.

People were involved and consulted in all decisions made about them. People told us they were very satisfied with the care provided and said staff treated them with dignity and respect. We found people were given their medicines when they needed them and in a safe way. Staff were supported to provide appropriate care and treatment to people through regular training and supervision.

The people living in the home told us they liked the home and were happy with the care being provided by the staff. One person who lived in the home said 'the home is very clean and cheerful' and 'It's so nice living here'. Whilst a visitor told us that staff were 'responsive and responsible.

We found that people were listened to before and during their move into the home and their comments were acted upon.

People told us their care and support met their needs and that staff treated them with respect.

People living in the home told us they felt safe and the people visiting the home confirmed that they felt their relatives were safe and well cared for.

We found the home clean and tidy and saw that people were cared for in a clean, hygienic environment.

We followed up concerns about staffing levels in the home; on the evidence available to us we found there were enough staff to meet the current needs of people living in the home.

The provider had robust systems in place to regularly assess and monitor the quality of services that people received.